Chapter Title 2

DEPARTMENT OF NURSING

THE PRACTICE OF NURSING2018 ANNUAL REPORT

Introduction 1

Greetings Colleagues,

It is with immense pride and appreciation that I share the 2018 Boston Medical Center Nursing Annual Report. I am awed by the accomplishments of our nursing staff. In the past 12 months, we have lived our core values: Built on Respect, Powered by Empathy; Move Mountains; and Many Faces Create Our Greatness. This year, we completed our campus consolidation balancing the workforce challenges of this transition, the clinical needs of our patients, and our commitment to celebrating the legacy of our past.

We have experienced unprecedented growth in our patient volume requiring examination of how we provide exceptional care. Throughout our many challenges, we hold steadfast to our core values and our ability to maintain a culture of respect, empathy, caring and compassion. Our annual report provides examples of our work and highlights the professional nursing practice here at BMC.

Patient care is optimized when nurses work together to deliver highly reliable care: care that is evidence-based and that results in continuous improvement in quality, with safety in our quest for Zero Harm. In this report, you will read about some of the outstanding accomplishments of our nurses and interprofessional teams that have allowed us to progress toward our goals. These efforts have resulted in decreased infections, improved medication safety, minimization of falls and enhanced transitions of care for our patients.

So many of our nurses have fully embraced our shared governance structure; engaged in professional development and education; embraced peer feedback and accountability, and participated in robust quality improvement, and evidence-based practice. I hope you enjoy the stories in this report that highlight some of this great work.

Thank you for the expert, compassionate care that you provide for our patients and colleagues and for leading the way in nursing excellence.

With my sincerest appreciation,

NANCY W. GADEN, DNP, RN, NEA-BC

Senior Vice President and Chief Nursing Officer Boston Medical Center

PUBLISHED BY Boston Medical Center Department of Nursing

PUBLISHERNancy W. Gaden, DNP, RN, NEA-BC

MANAGING EDITORSDiane Hanley, MS, RN-BC, EJD Erlyn B. Ordinario, MA

DESIGNERGinny Warren

CONTRIBUTORSBusayo AjayiAnn CareyKrissy CoffeyCarol ConleyGen ConlinPamela CoreyKim CostelloChristine DeAngelisSarah EvansMaggie FauldsDoris FoleyEduarda FonsecaDiane HanleyDonna HarveyJoanne HoganJennifer JarbeauAllison KaelbleinCathy KornNicole LincolnAmanda MartinMaureen McMahonSheila MurphyErlyn OrdinarioJennifer PlummerKarin RalloSteven SainteGeralyn SaundersLisa Zani

PHOTOGRAPHYErlyn B. Ordinario, MA

74% WHITE

16% AFRICAN AMERICAN

5% ASIAN

4% HISPANIC OR LATINO

1% TWO OR MORE RACES

<1% AMERICAN INDIAN OR ALASKAN NATIVE

<1% NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

2 Boston Medical Center Nursing Department

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REGISTERED NURSES1634

367 CNAS & LPNS

ADVANCED PRACTICE NURSES250

Mission Statement EXCEPTIONAL CARE WITHOUT EXCEPTION

Boston Medical Center nurses are leading the improvement of health and health care and strengthening the discipline of nursing through new knowledge, innovations, and improvements. Each day, front-line nurses and nurse leaders in every corner of our system of care are advancing professional practice, clinical inquiry and the delivery of evidence-based care to the patients, families, and the communities we serve regionally, nationally, and around the world. In partnership with patients, families, physicians, nurses, and other caregivers at Boston Medical Center provide a high level, consistent standard of care by identifying patient needs, defining expected outcomes, and respecting patient rights. Using the patient-centered care model, over 1,600 nurses in our system are driven to prioritize patient needs and demonstrate and deliver Exceptional Care Without Exception on a daily basis.

Nursing Commitment to Professional Practice

Boston Medical Center (BMC) has developed and adopted a professional practice model that serves as an underlying framework for all we do, unifying BMC nurses around a common belief system. It reflects the care nurses provide to our patients, aligns with the BMC mission, and emphasizes BMC’s core values and overarching goals. BMC nurses consider and incorporate those meaningful values into each patient’s plan of care, ensuring that patients and families feel respected and well-served. Additionally, nurses at BMC focus heavily on providing culturally competent care, creating goals and nursing interventions that incorporate the cultural values important to their patients and families. BMC nurses are committed to our care delivery model, patient-centered care, and shared governance, as both are core components of our professional practice model.

Patient Centered Care

Shared Governance

Com

passionate Care, Respect, Cultural Values

Effect

ive Communication, Teamwork, Accountability

Integrity, Advocacy

Evide

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Based Practice, Innovation, Professional Development, Patient Safety

Nursing Professional Practice Model

YEARS OF EXPERIENCE

ETHNICITY

Boston Medical CenterDepartment of Nursing is Committed to Professional Practice

FEMALE90%

RNS WITH BSN, MSN, OR PHD 71%

11% RNS WITH SPECIALTY CERTIFICATIONS

Our Nursing Professional Practice Model*

* Special thanks to the clinical nurses at Council Congress and throughout BMC who designed and implemented our nursing professional practice model.

10-19 YEARS

< 9 YEARS

45+ YEARS

30–45 YEARS

20-29 YEARS

4%

36%

20%

22%

18%

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BEDS514

1.1M+ OUT- PATIENT VISITS

ER VISITS132K

25+K2018 INPATIENT ADMISSIONS

BMC’s innovative programs are nationally recognized models and make an impact on the social determinants of health.

Hunger • Demonstration Kitchen • Therapeutic Food Pantry

Homelessness • Elders Living at Home • HUES to Home

Children’s Health • Child Witness to Violence • Pieces of Home

Urban Violence • Violence Intervention

Advocacy Program (VIAP)

BMC by the numbers

Busiest Emergency Department in New England, 12th busiest nationwide

14 health centers in our network

New England’s largest safety net hospital

15th in the nation for NIH funding

6000+ hospital employees

450,000 health plan members

750+ Physicians

817 Residents and Fellows

1,634 Nurses

Patients BMC serves

70% are underserved minorities (60% black, 10% hispanic)

30% do not speak English as their primary language

50%+ have an annual household income below $20,400 (close to the federal poverty line for a family of 3)

80%+ of patients are publicly insured or uninsured

Substance Abuse Treatment and Prevention

• ABOVE (Psychiatry) • Addiction Consult Service • CATALYST (Adolescent and Young Adult Care) • FAST PATH Infectious Disease Care • Faster Paths to Treatment • Office Based Addiction Treatment (OBAT) • Project ASSERT • Project RESPECT • SO FAR (Pediatric Care)

Improving communication and patient experience is a major priority at Boston Medical Center. As we considered the nurse handoff, which is an integral part of the daily routine of a nurse, we examined the change of shift report. While this part of the routine exists for all BMC nurses, the methods used in executing a handoff varied among nurses and across units. Historically, it has taken place away from the patient’s bedside and out of the patient’s room. The handoff had not typically included the patient, nor did it allow an opportunity for the patient to participate in their own care. After identifying the handoff routine as an opportunity to improve the patient experience and patient safety, BMC adopted a standard evidenced-based tool called I-PASS. I-PASS, an acronym for Illness severity, Patient summary, Action plan, Situation awareness, and Synthesis, covers each of the critical components of a verbal handoff. And, by moving the nursing report to the bedside, patients now have the opportunity to engage in their own care. Adopting this consistent method of executing the handoff, in addition to moving the action to the bedside, BMC has effectively improved communication, collaboration, and increased the level of respect shown to each patient. Patient safety is a focus of all we do and this mechanism of bedside reporting is one of the tools we use to optimize patient outcomes.

Patient Experience

BEFORE AFTER

Percentile rank of communication between patients and 6W nursing staff before and after implementation of bedside reporting

9% 64%

18% 55%

3% 77%

COMMUNICATION WITH NURSES

NURSES TREAT ME WITH COURTESY AND RESPECT

NURSES LISTEN CAREFULLY TO ME

POWERED BYEMPATHY

BUILT ON RESPECT

HCAHPS Patient Survey Results

8 Boston Medical Center Nursing Department Built on Respect, Powered by Empathy 9

Clinical Outcomes

CLABSI

Central line-associated bloodstream infections (CLABSI) result in thousands of deaths each year and billions of dollars in added costs to the U.S. healthcare system, yet these infections are preventable. At BMC, a hospital-wide interprofessional taskforce was assembled to strategize around ways to decrease the occurrence of CLABSIs.

Recent change ideas include extending chlorhexidine gluconate (CHG) baths to non-intensive care units; creating a decision tree to decrease the amount of central-lines used; and increasing peripheral/midline use. Teams utilize standard checklists, structured physician order sets, and evidence-based algorithms. Hospital-wide metrics reveal that BMC is outperforming the National Database of Nursing Quality Indicators (NDNQI) national benchmarks for all of 2018.

CAUTI

Despite its preventability, hospitals across the country continue to struggle with catheter associated urinary tract infection (CAUTI). The National Healthcare Surveillance Network (NHSN) reported 25,281 CAUTIs nationwide in 4,543 acute care/critical access hospitals (CDC, 2019). In 2018, nurses and the interprofessional team instituted several best practices aimed at reducing the risk of catheter associated urinary tract infection.

These best practices included: a nurse-driven bladder management protocol to promote early removal of catheters; use of a female incontinence device in the critical care and stepdown areas to monitor urine output with an external device; implementation of a bladder scanning protocol; and a urinalysis to culture reflex protocol. Policies were developed and staff were educated through on-line learning and face-to-face teaching.

The most important factor in reducing the risk of catheter-associated urinary tract infection is limiting the number of days that a patient has a chronic indwelling catheter. The National Healthcare Safety Network (NHSN) uses the Standardized Utilization Ratio (SUR) to monitor device utilization amongst hospitals. From 2015 to 2018, the SUR decreased from 0.718 to 0.513. The current BMC SUR is 50 percent below the National Benchmark.

Maternity Patient Experience

Patient experience in Maternity showed positive growth in 2018. Nursing leadership started formal rounds and purposeful staff rounding on all maternity units. Operational improvements were also identified as an area to target with regard to impacting the patient experience.

Nurse leaders, clinical nurses, and the interprofessional team conducted a current state analysis using a shared governance model and utilized Institute of Healthcare Improvement (IHI) and lean management principles to achieve positive results. Several improvements were made:

• Registration was moved to the Labor and Delivery suite

• A redesign of the nurse workflow was instituted

• Nurse/Provider communication scripts were developed in Epic, BMC’s electronic medical record system

• A dedicated pager and enhanced alerts were implemented to increase provider triage communication and capabilities

• Blood draws for patients with hypertension were implemented through nurse-driven protocols

• A resident triage guide was created to facilitate adoption of workflows by new providers

Mother/Baby Discharge Planning

Nurses on our Mother/Baby unit designed an initiative to improve discharge times in 2018. Barriers were identified and workflows streamlined to make the discharge process more efficient. This included:

• Improving efficiency in acquiring car seats• Streamlining the approach to the birth

certificate process • Bringing discharge medications to the bedside • Proactively identifying options for the

mother and baby to be transported home

Early discharge rates have improved to include an additional 1-2 patients each day, resulting in more open beds for post-partum patients from Labor and Delivery.

0

0.3

0.6

0.9

1.2

2015 2016 2017 2018

BMC SUR GOAL < 1

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1.05

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2017 Q4 2018 Q1 2018 Q2 2018 Q3 2018 Q4

BMC National Benchmark

The nurses at BMC are committed to continuous improvement of the delivery, quality, efficiency, and outcomes of nursing practice. This continuous improvement is accomplished by systematically collecting data, performing a review and analysis of that data, and using newly developed knowledge to inform decision-making, evaluation, and implementation of improvement activities to ultimately create a positive impact on patient outcomes.

Urinary Catheter Device Standardized Utilization Ratio

Pursuing the aforementioned improvements resulted in a decrease by 45 minutes in triage and a decrease time in overflow by 25 minutes. Staff audits and just-in-time feedback were helpful in sustaining these changes. By using these strategies, overall patient satisfaction yielded positive results: nurse communication improved from 82.2 percent to 84.5 percent, nurse responsiveness improved from 69.1 percent to 72.2 percent, and the overall rating of the unit improved to 75.1 percent.

Central Line-Associated Bloodstream Infections Rate/1000 line days

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2017 2018

“Stunning” Improvement in Patient Experience

74% 88%

73% 78%

70% 78%

71% 75%

77% 82%

FRIENDLINESS OF NICU NURSES

INSTRUCTIONS ABOUT CHILD

ATTENTION TO PERSONAL NEEDS OF THE CHILD

NICU KEPT ME INFORMED

SKILL OF THE NICU NURSE

AIDET

Evidence links improved patient satisfaction scores to the use of AIDET (Acknowledge, Introduce, Duration, Explanation and Thank You). AIDET is a conversation framework used when communicating with patients to decrease patient anxiety, increase patient engagement, and improve patient safety and outcomes.

Utilizing simulation activities, BMC has educated all nursing department staff interacting with patients how to effectively use the AIDET framework to communicate with patients, their families, and fellow colleagues.

• Acknowledge: Greet people with a smile and use their names as you care for them.

• Introduce: Introducing yourself to others in a warm and friendly manner tells them who you are and how you are going to help them.

• Duration: Give an accurate time expectation for tests, physician arrival, and identify next steps for plan of care.

• Explanation: Explain step-by-step what the patient should expect next, answer any questions, and let the patient know how to contact you or others if they need you.

• Thank You: Thank the patient and/or family. Express gratitude to them for choosing BMC or for their communication and cooperation.

At BMC, we take pride in the excellent care provided to our patients.

Leader Rounding

At Boston Medical Center, we pride ourselves on providing Exceptional Care Without Exception and there are a few things more satisfying than hearing the feedback from patients and staff, affirming that we really do “talk the talk, and walk the walk.” Leader rounding on the inpatient units is a best practice that measures and validates our efforts toward creating an exceptional patient experience, giving patients and family members a real-time opportunity to give feedback to the organization, the unit, and the staff members providing direct care.

Frequent and purposeful rounding with staff members allows for timely identification and resolution of issues. Hearing first-hand feedback identifies what is working and what needs greater focus, keeping the unit culture positive and moving forward. Sharing general themes in staff huddles and across varied other unit communications also keeps the whole team accountable, informed, and involved.

Many great initiatives, outcomes, and peer recognition have come from rounding. It is the rewarding “thank you” from a patient or coworker that makes long shifts feel shorter and reminds you why you are so proud to be a nurse.

Teach-back to Enhance Patient Education

Teach-back is an evidence-based method utilized across the healthcare continuum to enhance patient education. Patients typically forget, or remember incorrectly, over half of the medical information taught to them.

Teach-back provides an opportunity for nurses to assess a patient’s understanding of new concepts and prepares them for self-care after discharge. The patients will teach-back the key information about their care in their own words and/or demonstrate newly taught skills. Nurses can then clarify misunderstandings with the patient in real-time.

Teach-back modules for patient education were created by nursing unit-based council members in several medical-surgical units and have been brought to the nursing councils for review. There are currently four teach-back modules available for use in Epic, BMC’s electronic medical record system. The first teach-back modules available are: COPD (chronic obstructive pulmonary disease), heart failure, Enoxaparin (Lovenox), and fall prevention. There are teams at BMC currently using the COPD and heart failure teach-back modules with great success and as a result, have reduced readmissions and improved patient outcomes.

NICU Communication with Families

Communication and respect were the hallmarks of patient nurse interaction in the NICU in 2018. NICU nurses drove an initiative with the goal of ensuring each family had a family meeting with their healthcare team. The whiteboard found in each patient’s room was used to communicate the booking of the meeting. The NICU nurses also implemented AIDET (Acknowledge, Introduce, Duration, Explanation, Thank You) techniques in their communication with parents. Patient experience scores greatly improved in several areas and patients more engaged in their own care have better outcomes.

HCAHPS Percent “Always”

Built on Respect, Powered by Empathy 1312 Boston Medical Center Nursing Department

Care Management Initiatives

Care Management continues to thrive in developing programs to coordinate the care of patients and assisting patients and families as they navigate the health care system. This includes advocating for the needs of patients and families in the community, helping them cope with the emotional impact of illness, negotiating with insurance and managed care companies, discharge planning, and other assistance. Two programs initiated at BMC in 2018 include safe discharge and guardianship programs.

The safe discharge program provided patients who were uninsured better access to, and coordination of, care. BMC nurse care managers partnered with three nursing homes to provide outpatient rehabilitation, education, and services to assure patients are safely discharged.

The Care Management team also worked with the BMC legal and medical teams to develop a guardianship program. Through this program, any patient unable to make health care decisions on their own behalf would defer to a guardian as their health care proxy. This legal advocate for the patient would complete all necessary documentation. To date, the team has worked on over 100 cases, assuring patients get the right care, in the right place, at the right time.

Driving Improvements in the Gynecology Procedural Unit

In 2018, nurses were involved in many quality improvement activities throughout ambulatory. One is the improvement of patient flow in the Gynecology Procedural Unit (GPU). With an increase in patient flow, additional access was created for minor gynecological surgical cases considered medically appropriate for an ambulatory outpatient setting. Patient experience improved, resulting in decreased wait times for surgery appointments. The GPU setting was also more cost-effective than a traditional operating room setting.

Moreover, new workflows were created to take care of the GPU patients. Six nurses received training to care for acute post-operative patients. Pre-op intake, procedure room turnover, and post-op recovery workflows were streamlined. Pre-op education sheets, post-op instructions, and discharge teaching were all updated. With Nursing driving this initiative, processes, in-services, and targeted education were implemented thereby supporting staff and patient engagement. As a result of this innovative workflow development, nurses, providers, and patients expressed increased satisfaction.

Managing Asthma for Children

In 2018, the primary care clinics and adolescent clinics implemented a process to better manage asthma patients over the age of four. The Asthma Control Test (ACT) is an assessment completed by nursing staff with a goal of improving quality of life and reducing cost of care. Any patient seen in the adolescent or primary care clinics who have an asthma diagnosis or albuterol prescription were to be screened using a validated questionnaire to assess home management of their asthma. Staff champions were identified and data metrics of completed assessments were disseminated to staff by way of weekly newsletters and a quality dashboard. Prior to the initiative, the baseline completion rate was 8%. Following implementation, the assessment rate was over 90% by September.

photo by John Horner

Move Mountains 15

Consolidating Our Campus

During the month of October 2018, all patient units within the 88 East Newton Pavilion were relocated to the main campus’ Menino building. This effort was the culmination of thousands of hours of logistical coordination and training both on the Menino and East Newton Campus since 2016.

MOVEMOUNTAINS

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INPATIENT UNITS MOVED22

15 ANCILLARY SUPPORT AREAS MOVED

A critical key to the success of the moves was communication. In early 2017, a website was developed as a campus integration resource for staff. The site provided timelines, key milestones, and information about each of the future units. Updates on the project were provided through open forums, staff rounding, newsletters, and through attendance at Nurse Practice Council.

Programs and tools were developed to foster integration of new teams and better understand the change process. A full day resiliency program was offered monthly with over 300 nurses attending.

Coordination of logistics involved a number of teams from many disciplines. Teams within nursing were developed for equipment planning and for move assistance. For each move, an “expert move team” consisting of float nurses assisted in preparation for the move. On move day, staff had defined roles for sending and receiving of patients in order to ensure a consistent approach and attention to patient safety.

The move staff were able to attend to global logistical issues around the move which then allowed primary nursing staff to focus on caring for their patients. At the conclusion of each move, the expert float team assisted with getting patients and staff settled into their new area. The staff were the true heroes of the move effort!

While Boston Medical Center (the former Boston City Hospital and University Hospital) has been a merged entity for a number of years, many of the staff had worked only at one campus. In order for the move to be a true success, an opportunity to honor and celebrate the legacy of the University Hospital would be important for staff who closely aligned with the East Newton Campus.

A team of nursing volunteers was formed in the Spring of 2018. This group planned a number of celebration events in the months leading up to the move and developed significant opportunities for staff to connect with one another and say goodbye. A Facebook page was created for staff to share memories and all staff was offered keepsakes in the form of a yearbook and pin.

Together, these efforts and active staff involvement made the move a great success.

1030 STAFF INVOLVED

59 OUTPATIENT PROGRAMS MOVED

PATIENTS MOVED394

18 Boston Medical Center Nursing Department Move Mountains 19

Emergency Department Expansion

The Emergency department (ED) at Boston Medical Center evaluates nearly 132,000 patients annually. This translates to over 400 patients per day coming through our doors with approximately 300 registered nurses caring for patients.

BMC is the 12th busiest emergency department in the country and treats the highest volume of trauma victims in New England. Over the past few years, we have ‘Moved Mountains’ and are nearing the completion of a 5-year ED expansion project. Construction was done in areas of continual phasing, each project methodically leading to the next. Physical spaces were modified around clinical operations, while patient volume grew at 2 percent annually. The nursing staff in the ED continue to support one another and ensure that our patients receive the care they need and deserve.

A Pathway for Pediatric Trauma Patients

In the Pediatric Emergency and Trauma program, BMC receives nearly 25,000 visits annually. Built in 2018, the brand new, state-of-the-art pediatric unit includes 14 dedicated beds and a modern, family friendly waiting room.

One of the most notable highlights from last year was the creation of a pediatric trauma pathway for patients. Many children with traumatic injury have poor health follow up. They have extended leaves from school and a high rate of return hospital visits.

This nurse-driven pathway improved the care of patients beyond the injury presented and included assessment of housing, food insecurity, shelters, and available caregivers in their lives. Identifying these needs early on resulted in additional time, resources, education, increased social work presence, and facilitation of school accommodations. Eighty patients benefited from this pathway in the first year alone. With nurses and clinical staff coming together and advocating daily for changes in practice, BMC was able to tailor care around our most vulnerable patients.

Nursing Always Prepared in Emergency Situations

During 2018, Nursing played an integral part in the campus consolidation, ensuring continuity of clinical operations and patient safety during 45 planned disruptions of utilities and infrastructure needed to complete construction. Nurses truly moved mountains during the final stages of the campus consolidation. A total of 394 patients were moved without a single adverse outcome since the moves began in 2016. The herculean effort required complex bed management, adherence to procedures, cooperation, and most of all a focus on safety for all patients.

Other highlights:

• Nurses participated in the 2018 Region 4C Hospital Evacuation Exercise. This helped inform BMC’s evacuation plans.

• Nursing leaders and clinical nurses from the BMC Special Pathogens Unit continue to ensure an effective response to highly infectious diseases. The National Ebola Training and Exercise Center conducted a survey of BMC’s Special Pathogens program and received excellent reviews and compliments to staff.

• When the City of Boston saw a cold snap in January, a pipe burst that affected the BMC Labor and Delivery and NICU units. Maternity staff, command operations and the clinical teams worked to ensure that laboring patients were triaged in the Emergency department and units merged to accommodate the transfer of the babies within BMC. The staff were able to safely evacuate the babies in the flooded units in less than 45 minutes.

In March 2018, Boston Medical Center Health System (BMCHS) became a Medicaid accountable care organization (ACO) to transform how care is delivered and improve the health for some of the state’s most vulnerable patients. The Boston Accountable Care Organization (BACO) is a partnership among BMC, BMC physician practices, community health centers, provider groups, and the BMC HealthNet Plan. When our Medicaid ACO launched so did a Complex Care Management (CCM) program: a nurse-led, community-based intervention for patients whose health care needs placed them in the top 2 percent of ACO patients. Nurse-led complex care management is critical to bending the curve for our highest risk ACO patients.

Nurses serve as clinical anchors to our CCM teams and work in partnership with community wellness advocates, pharmacy staff, and providers to assess and intervene with patients in the community. As expert clinicians and collaborators, they develop patient-centered care plans focused on social determinants and chronic disease management. CCM nurses educate and coach patients with highly complex social, medical, and behavioral health needs. Some of the most prevalent conditions addressed include major depression, hypertension, substance use disorder, serious mental illness, heart failure, homelessness, and diabetes. Nurses often engage patients in CCM during catalytic change points, hospitalization, emergency room visits, or crisis situations addressing immediate needs and progressing to an authentic caring relationship aimed at promoting patient self-efficacy.

Examples of success stories include a woman with chronic kidney disease, second grade literacy, type 2 diabetes, and a right below knee amputation at risk of becoming homeless. Her immigration status rendered her ineligible for many government benefits. The CCM team assisted with chronic disease management, acquired income through the Department of Transitional Assistance’s EAEDC (Emergency Aid to the Elderly, Disabled and Children) Disability program, and helped with the processes for U.S. citizenship and housing applications. She was recently housed in Boston (pictured left) and became a naturalized citizen in February. Efforts like these are having profound impact on high cost health care utilization. They are not only reducing hospitalizations and emergency room visits, but they are also increasing engagement in appropriate outpatient care.

Early outcomes of the nurse-led CCM program are extremely promising. In the first year, CCM teams have enrolled more than one thousand patients. Patients who actively engage with CCM demonstrate 30 percent reduction in inpatient admissions and 13 percent reduction in emergency room visits. As the program embarks on year two, CCM will further refine its approach to benefit more patients and develop resources to prevent unnecessary health care utilization.

BMC Health System Complex Care Management Nurses Moves Mountains for High Risk ACO Patients

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Telesit: Innovation in Patient Observation

Nursing launched an exciting new program for patient safety observation in April 2018. The telesit remote video monitoring initiative is a cutting-edge approach to managing the need for continuous monitoring while providing safe and efficient care. The program was developed in collaboration with the Float Pool Unit Based Council, who worked to develop the policy and procedure for safety video monitoring and the job descriptions for the telesit monitor, runner, and safety nurse.

The telesit program allows for remote video monitoring of 12 patients requiring continuous observation. Safety nurses work with telesit certified nursing assistants (CNAs) and the entire team to deliver efficient care to all patients ordered for continuous observation. With this program and evidence-based algorithms, we are able to provide the appropriate level of monitoring for each patient which allows for more CNAs to be available to staff the units.

As a result of the program’s success, telesit will be expanding to provide safe and efficient care to more patients. Safety nurses and CNAs will continue to work closely with staff on the units to achieve outstanding patient safety outcomes.

“Epic” RevUp Go Live: May 2018

Boston Medical Center began its journey with Epic in May of 2014. Epic was instrumental in creating one patient electronic medical record and initial implementation included the inpatient floors, emergency department, maternity and perioperative/procedural areas. Phase two included ambulatory practice areas with the final wave occurring in May of 2018 as finance, registration and scheduling system functionality were replaced by Epic.

With the 2018 go-live, BMC now has an automated real-time patient flow companion. The new Epic module ensures a seamless, efficient patient flow and allows for tracking from patient registration to bed planning, through transport and support services.

What does this all mean to Nursing? This system allows a consistent, updated unit census with accurate patient locations and provides standardization for our Unit Coordinators using Unit Manager as their primary tool. Patients are transported to their next phase of care in a timely fashion and the receiving unit has the information needed to welcome and prepare for the patient. It means Charge Nurses have capacity information and patient locations visible at all times. Bed Control receives automated notifications when a patient transfer needs to occur, and alert support services to service the room while prompting transport for drop off and pick up. All of this results in safer, timelier patient care.

Having this new longitudinal visibility, regardless of the patient setting, allowed our clinicians to focus on the patient and continue to provide Exceptional Care Without Exception.

Many Faces Create our Greatness 23

Many Faces Create Our Greatness

As the date for closure of the East Newton Pavilion drew closer, a group of nurse volunteers gathered to plan for ways to honor and remember the many years of practice and collegiality at the site. This site had been known by several names including University Hospital, Boston University Medical Center, and East Newton Pavilion and had held many cherished memories. Staff were invited to share pictures on a Friends of University Hospital Facebook page.

Events were held during the summer of 2018 including catered Chinese meals and ice cream socials for all shifts and an (indoor) summer street fair with hot dogs, music, and entertainment. There was a large-scale celebration in August which included formal remarks from past and present leaders including Karen Kirby, former Chief Nursing Officer, Nancy Gaden, Chief Nursing Officer, and Kate Walsh, President and Chief Executive Officer. The committee worked tirelessly to contact former staff and attendance at the event exceeded 300 people. The staff had an opportunity to reminisce and catch up as they enjoyed displays of mementoes from the past, a photo booth, and basket raffles. A yearbook and a pin were given as keepsake items.

East Newton & University Hospital Celebration

On Thursday August 16, nursing colleagues, retirees, alumni and former University Hospital nursing leadership reconnected, celebrated and honored the contributions and legacy of East Newton Pavilion and University Hospital.

CREATE OURMANY FACES

GREATNESS

24 Boston Medical Center Nursing Department Many Faces Create our Greatness 25

Recruiting and Celebrating Veterans at BMC

This year, BMC embarked on a journey to increase our veteran population, specifically among clinical staff. The team reached out to current veterans that work at the hospital to provide details about their experience transitioning from the military to civilian clinical work. One of the successes from this endeavor was a signed private-public partnership with the 99th Army Reserve. This increased our visibility with organizations that recruit directly from veteran groups including Edge4Vets.

In addition, our nurse veteran leaders made a concerted effort to hire veterans and active reservists from the community, specifically in our procedural units and in our Trauma department. Through our various endeavors we have been able to increase engagement of current employees who are veterans and active service men and women as well hiring veterans across the organization from non-clinical areas. We are excited about our recent engagements and hope to continue to build our momentum in nursing recruitment.

Clinical Nurses Drive Successful Onboarding

Throughout 2018, clinical nurses from the step down units successfully hired and oriented 47 nurses. Within this group, there were a total of 12 newly licensed nurses who participated in the comprehensive new graduate residency program. In addition to the new graduates, the step down units hired several nurses with varying levels of medical-surgical experience. Many of these nurses were interviewed and hired by a panel of nurse leaders and clinical nurses. These new nurses came to BMC at a time of great transition and the hiring was done in preparation for the merge between the two campuses.

The successful orientation of this large number of new staff required a tremendous commitment from the step down nursing teams. Clinical nurses worked tirelessly as preceptors during the year, never wavering on their commitment to their many orientees. In addition to dedicated preceptors, consistent and continued collaboration between the nurse managers and nurse educators of these units was essential to ensuring that new nurses were successfully progressing through their orientation. We are pleased to have so many eager new members on our team and we are delighted that they were brought into a culture that is so supportive of their needs. As a result of the team’s efforts, there is currently less than a 1% vacancy rate in the step down units.

26 Boston Medical Center Nursing Department Many Faces Create our Greatness 27

Experienced RN Transition Program

The successful transition of our BMC experienced nurses to a specialty practice is a priority. As an expert nurse transitions to a new specialty, there is a need for a specific orientation to help the nurse regain expertise. This facilitates the transition to specialty practice and contributes to the retention of qualified nurses and safe patient care.

With BMC’s Experienced Nurse Transition program, the success of the transitioning nurse is assured through a robust program and support from preceptors, mentors, and peers. The primary purpose of the orientation program is to provide each nurse with the skills needed to function independently and competently in specialty nursing practice. Since BMC has offered the transition program, 43 nurses have successfully transitioned to new specialty areas.

New Graduate RN Residency Program

Our highly regarded and competitive new graduate RN residency program continues to thrive at Boston Medical Center. In 2011, the Institute of Medicine, in collaboration with the Robert Wood Johnson Foundation, published the Future of Nursing report that recommended the “implementation of nurse residency programs to support a successful transition from new graduate nurse to RN” (IOM, 2011). The residency program follows the key areas identified in the Casey-Fink survey of new graduate needs (Fink, Krugman, Casey, & Goode, 2008). The overarching educational model is Benner’s novice to expert model.

This 6-month program offers new graduate nurses an opportunity to integrate the nurses into the organization with close attention paid to the professional nursing role, clinical skills, and cohort socialization.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park: Addison-Wesley. Fink, R., Krugman, M., Casey, K., & Goode, C. (2008). The graduate nurse experience qualitative residency program outcomes. Journal of Nursing Administration, 38(7), 341-348. Institute of Medicine (2011). Future of nursing leading change, advancing health. Washington DC: National Academies Press.

The residency program consists of a faculty model for the first 3 weeks. The new graduates work with a clinical nurse educator learning basic clinical skills, quality initiatives, nursing sensitive indicators, and nurse of the future core competencies.

The new graduates meet every two weeks, attending seven clinical-focused classes, simulations, and specialty education. These classes incorporate didactic as well as hands on skills stations.

Feedback on this program from the new graduate nurses and preceptors on the units have been overwhelmingly positive. Our new graduate nurses complete this program competent and confident to practice as a professional nurse in an urban level one trauma teaching hospital.

“Mentoring nurses in a new specialty has been one of the high points in my career.” – TRANSITION PROGRAM PRECEPTOR

“Change is scary but this program provided me with an opportunity I thought I would never have.” – TRANSITION PROGRAM NURSE

Professional Practice 29

Our professional practice model ensures that our practice is consistent regardless of where the care is provided.

Patient Centered Care

BMC nurses embrace our care delivery model which is Patient Centered Care – “care that is respectful of, and responsive to, individual patient preferences, needs and values, and ensuring that patient values guide all clinical decisions” (Institute of Medicine, 2015).

Patient centered care is the practice of caring for patients and their families in ways that are meaningful and valuable to the individual patient. It includes listening to, informing and involving patients in their care. As advocates, BMC nurses provide compassionate care with dignity, respect and sensitivity to patients’ cultural values and autonomy.

Shared Governance

BMC nursing leadership endorses and celebrates shared governance. Shared governance is collaboration among all nurses, whether in scheduling staff, educating new staff, or implementing evidence-based practice. It involves teamwork, problem-solving, and accountability, with the goals of improved staff satisfaction, productivity, and patient outcomes. It is working together to make decisions that affect nursing practice and patient care. We are committed to interprofessional collaboration with patients as the focus of all we do. BMC believes that institutions that utilize shared governance at the organizational, departmental, and unit levels experience decreased turnover rates, increased nursing satisfaction and better patient outcomes.

BMC Nursing Philosophy: Nurse Theorist Dr. Madeleine Leininger

The Cultural Care: Diversity and Universality Theory was developed to guide in the provision of culturally congruent nursing care provided to diverse populations. BMC Professional Nurses embrace their duty to provide supportive care that is tailored to specific individual and groups and consider what is culturally valued and believed by those populations. BMC nurses consider and incorporate those meaningful values into the patients’ plan of care so patients and families feel respected. Nurses at BMC create goals and nursing care interventions that incorporate special cultural values important to their patients and families. Our diverse patient population has better outcomes because of the adoption and enumeration of this theoretical framework.

Professional Practice OverviewPRACTICE

PROFESSIONAL

30 Boston Medical Center Nursing Department Professional Practice 31

The 2nd Annual Nursing Council Congress

Over 100 staff nurses and leaders attended the 2nd Annual Nursing Council Congress in March. This forum highlighted accomplishments within the unit based councils, Nurse Practice Council, Nursing Informatics Council, Integrative Nursing Council, and several nurse-driven committees such as NICHE. Nurses also spent a good part of the day examining nursing practice and professional development at BMC.

Nursing Informatics Council

The Nursing Informatics Council (NIC) involves clinical nurses at BMC in the optimization process of Epic, BMC’s electronic medical record system. Having direct caregivers drive decision-making on proposed changes leads to overall system usability. Today, NIC membership includes 13 original members plus clinical staff from all areas of the hospital system. On average, more than 50 nurses gather monthly to drive Epic improvements that would enhance staff efficiency and adoption.

NICHE: Nurses Improving Care of Healthsystem Elders

Boston Medical Center received NICHE (Nurses Improving Care of Healthsystem Elders) designation. NICHE is a premier national geriatric nursing program that addresses the needs of hospitalized older adults and works to ensure that adults age 65 and over receive care that promotes function, autonomy and dignity. They are the leading nurse-driven program designed to address the complex needs of older adults. Through this program, many BMC medical-surgical nurses received certification as a Geriatric Resource Nurse and the program continues to grow.

Integrative Nursing Council

The Integrative Nursing Council (INC) promotes integrative health self-assessment for BMC nurses and provides opportunities to support nursing self-care. Members compose and review integrative nursing policies and guidelines to prepare for submission to the Nurse Practice Council. The INC identifies the need for and facilitates offerings of educational initiatives on integrative nursing topics to improve both nursing and patient satisfaction in addition to the quality of patient care (e.g. reiki, aromatherapy, and guided imagery).

The council acts as a resource to nurses who aim to implement integrative nursing practices in their clinical areas, share integrative nursing projects, policies, and initiatives with BMC nurses through the council representatives and establishes a task force for planning the Annual BMC Integrative Nursing Conference.

Nurse Practice Council

The Nurse Practice Council at Boston Medical Center promotes the development of nursing practice that is evidenced-based and congruent with nationally recognized standards of professional practice. Members, comprised of staff nurses and leaders, direct formation of task forces and subject matter groups for in-depth study of specific nursing practice issues. In addition, the council oversees development, review, and revision of policies and procedures and evaluates nursing practice based on established quality outcome measures.

Unit Based Councils

Nursing shared decision-making through our Unit-Based Councils (UBC) provides direction and support for the professional practice of nursing at BMC. This allows nurses to have an active voice on vital and necessary changes that occur throughout the organization as well as share ideas and achieve outcomes through effective and innovative methods.

Some examples of UBC activities:• The step down unit implemented a pain

assessment protocol to ensure a thorough and complete evaluation. Pain is re-assessed with a change in caregiver, after a significant change in the patient’s condition, upon transfer from one care to another, post-procedure and upon discharge.

• The Mother/Baby UBC conducted individualized high touch communication approaches with a focus on patient-centered care. These approaches included saying the mother’s name and family member’s names, writing the baby’s name on the whiteboard and having sibling carts stocked with materials for when siblings come to visit.

• The Medical Intensive Care Unit (MICU) and resource nurses worked on adult bereavement care for the families of their dying patients. Families receive a bereavement box that contains a music player, memorabilia, and other resources.

• Medical-surgical units continue to improve patient education and decrease readmissions using the teach-back method.

TOTAL PARTICIPANTS IN OUR PROGRAM OFFERINGS

3,325

135 PROFESSIONAL DEVELOPMENT PROGRAMS OFFERED

2,146 NURSES ATTENDED

CONTACT HOURS PROVIDED560

32 Boston Medical Center Nursing Department

Professional Development Activities

Selected Publications & Presentations

Throughout the year, nurses participate in many educational programs including simulation activities. Continuous professional development and learning is an integral part to providing exceptional care at BMC.

Sample of our programs:

• Domestic violence training • Opioid addiction • Transgender issues • Trauma • Preceptor development • Teams trainings • Integrative health and self-care • Resiliency • and many more

In our 2018 education year:

Nursing Professional Development at BMC

Nursing Professional Development at BMC is comprised of nurse educators who are experts in their clinical specialty. The nurse educators develop and implement a variety of programs to support all nursing staff (RNs, LPNs and Unlicensed Assistive Personnel) in the orientation, competency development, validation and ongoing professional development on the clinical unit, in simulation, in the classroom and e-learning. This hybrid education is designed to meet all levels of learners.

Programs include nursing orientation and annual nursing competency sessions that are specialty specific. Additionally, there are specialty programs for med-surg, ICU, stepdown, maternity, neonatal, pediatric, perioperative, emergency department and ambulatory care skill development. Nurse residency programs are offered for newly licensed nurses and experienced nurse transition programs for experienced nurses new to acute care or new to a specialty area.

Nursing Professional Development offers continuing education courses and supports staff in obtaining specialty certifications, such as the critical care nurse (AACN), medical surgical nursing (CMSN), etc. The professional development team is a driving force offering state-of-the-art nursing practice following national best practice standards that directly impact patient safety and quality.

Linda Alexander MSN, CWOCN What Every Health Care Provider Should Know about Patient Safety: Pressure Injuries, Chapter in OK to Proceed, BMC Publication 2018

Pamela Corey MSN, EdD, RN, CHSE Crisis Resource Management, Chapter in OK to Proceed, BMC Publication 2018

Jo Foley DNP, CNE, CCRN “The Integrated Clinical Experience” Poster Abstract at the MARILN Conference 2018

Roberta Gately RN, BA “Footprints in the Dust” a non-fiction memoir recounting time spent delivering humanitarian aid in war zones from Africa to Afghanistan.

Nancy Giacomozzi RN-BC, MEd, CNOR Presentation on “Documenting Across the Continuum: Tracking Intentionally Retained Foreign Objects (IRFO) in Trauma Patients” at the New England Informatics Council (NENIC) Annual Symposium, April 2018

Janine Hardman MSN, RN Presentation on “Vascular Team Initiation in the OR” at Boston Medical Center 2018

Anthony Shelton RN, OCN “Clinical Outcomes of Hypofractionated Stereotactic Body Radiation Therapy Boost for the Treatment of Localized, Non-Metastatic” at the High-Risk Prostate Cancer Conference, American College of Radiation Oncology (ACRO) Summit, February 2018

Larry Torrey RN Presentation on “Tales from the E.R. (Selected Case Studies)” and “Bleeding Control from the Inside Out” at the Texas EMS Conference, November 2018

Kristin Wason MSN, AGPCNP, CARN Presentation on “Medication for Addiction Treatment in Adolescent Populations” at the Massachusetts Department of Children and Families State-Wide Opioid Epidemic and Child Welfare Forum, November 2018

Deborah Whalen MSN, MBA, RNP Alarm Management, Chapter in OK to Proceed, BMC Publication 2018

Celebrations & Recognition 35

Four of our outstanding BMC nurses received the New England Regional Black Nurses Association Excellence in Nursing Awards at the 30th Annual NERBNA Award Dinner, held at the Boston Marriott in February 2018. We are proud of our nurses. It is through their excellence in practice and patient advocacy that we achieve Exceptional Care Without Exception.

Myrline Desormeau, BSN, RN, 7 East Sherine Henry, BSN, RN, 7 East Barbara Lewis-Thompson, ASN, RN, 6 West Jessica Sylvestre, LPN, Primary Care

NERBNA Excellence in Nursing AwardsRECOGNITION

CELEBRATIONS &

36 Boston Medical Center Nursing Department Celebrations & Recognition 37

NURSE HERO TIM CLYNCH, RN, RECOGNIZED AT THE BOSTON RED SOX NURSES NIGHT 2018

“Tim was honored and recognized for his heroic efforts when he witnessed a man go into cardiac arrest at the gym. He was able to immediately get bystanders to call 911 and use the defibrillator to shock the man’s heart back to life. Although the patient was a bit shocked when he woke up in the emergency room at Boston Medical Center, he was thankful to Tim for saving his life and some say that it was nothing short of fate that Tim happened to be working out at the same gym.

Tim is one of the everyday heroes who quietly goes about his work and practices bravery and selflessness without seeking or expecting recognition. His passion for the nursing profession and compassion for patients has never wavered and he manages to remain kind and respectful while also serving as a valuable example to others.”

Nurse Excellence Awards Mary Angelides, RN Dawn Casale, RN Katie Christopher, RN Rachel Fishman, RN Margaret Guerrera, RN Sharmecka Horton, RN Cathy Kane, RN Susan Link, RN Patricia McDougall, RN Jill Robertson, RN

Ann G. Hargreaves Award Abigail Brennan, RN

Peggy Cenci Memorial Award Skyla Barnett, RN

Lynn Ronan, RN Celebration of Life Award Cathy Angeley, RN

Friends of Nursing Dan Gavin, RT

19th Annual Nursing Excellence Awards

The Nursing Excellence Awards was held on May 9, 2018.

We congratulate all the nominees and award recipients for their compassionate and exceptional care provided to our patients.

Source: Nurse.org

38 Boston Medical Center Nursing Department Celebrations & Recognition 39

Nurses Week: May 6-12

Every year, we honor our nurses and the nursing practice at BMC through educational activities and simulation workshops, recognition programs and events such as our nursing craft fair and family day at Fenway Park. We celebrate our nurses and the exceptional care at BMC every chance we have.

Julie Swain, RN, received the DAISY Award for Extraordinary Nurses for her compassionate care. She exemplifies the kind of nurse our patients, families, and staff look to for support. The DAISY Award is an international nursing recognition program that was established in 1999 by the family of Patrick Barnes, who died at the age of 33 from complication of Idiopathic Thrombocytopenia Purpura (ITP). As a way to turn their grief into something positive, the Barnes Family came up with the DAISY Award, an acronym for Diseases Attacking the Immune System. The Barnes family believes nurses are the unsung heroes of our society who deserve far more recognition and honor for the compassionate care they provide to patients every day.

DAISY AWARD WINNER: JULIE SWAIN, RN

40 Boston Medical Center Nursing Department Celebrations & Recognition 41

Volunteering at the BMC Rooftop Garden

Last summer, nurses from Primary Care and the Step Down Unit volunteered at Boston Medical Center’s rooftop garden. Our rooftop garden supplies fresh vegetables and fruits to patients and the BMC community.

• Boston Medical Center was listed on Becker’s Hospital Review’s “150 Top Places to Work in Healthcare.”

• For the second year in a row, BMC received a Top 25 Environmental Excellence Award from Practice Greenhealth.

• BMC also won three Circles of Excellence awards from Practice Greenhealth, in energy, climate, and green building.

• BMC was designated a LGBTQ Healthcare Equality Leader by the Human Rights Campaign. The status is awarded to healthcare facilities that attained a score of 100 in the Healthcare Equality Index (HEI) 2018.

• BMC was named one of Becker’s Hospital Review’s “100 Great Hospitals in America.” Hospitals are chosen for this award based on their excellence in clinical care, patient outcomes, and staff and physician satisfaction.

• BMC nurses are recipients of the New England Regional Black Nurses Association Excellence in Nursing Awards.

• Over 30 BMC nurses were nominated by patients, families, and colleagues for their dedication and care for their patients in The Boston Globe’s 2018 Salute to Nurses. The Office Based Addiction Treatment Program (OBAT)’s nursing team was featured on the cover of the Salute to Nurses feature.

• Boston Medical Center received an “A” in patient safety from The Leapfrog Group’s Fall 2018 Hospital Safety Grade.

• Boston Medical Center Health System was named #1 on a list of the top 100 women-led businesses in Massachusetts by the Globe Magazine and The Commonwealth Institute.

Boston Medical Center Awards & Recognition

BOSTON MEDICAL CENTER

DEPARTMENT OF NURSING ONE BOSTON MEDICAL CENTER PLACE BOSTON, MA 02118

Email: nursinginfo@bmc.org Phone: 617.638.8000

www.bmc.org/nursing